When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their specific goals.

They believe that if they can be taught these skills, they will be able to overcome their difficulties, or the problems that led to them entering therapy, and they will have no subsequent difficulties or need for additional therapy going forward.

Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.

I do believe that if a client is able to have more helpful cognitions and behaviours then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).

What actually leads to improvements across treatment?

The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)

The therapeutic relationship (30% of overall outcome variance)

The expectations about the treatment and therapy (15% of overall outcome variance)

The specific model of treatment (15% of overall outcome variance)

For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.

What do clients view to be the most valuable elements of therapy once they have improved?

By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.

In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most helpful therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them in terms of how helpful these items were across their treatment.

The 12 categories, from least helpful to most helpful were:

12. Identification: trying to be like others

11. Guidance: being given advice or suggestions about what to do

10. Family reenactment: developing a greater understanding of earlier family experiences

9. Altruism: seeing the benefits of helping others

8. Installation of hope: knowing that others with similar problems have improved

7. Universality: realising that others have similar experiences and problems

6. Existential factors: recognizing that pain, isolation, injustice and death are part of life

5. Interpersonal output: learning about how to relate to and get along with others

4. Self-understanding: learning more about thoughts, feelings, the self, and their origins

3. Cohesiveness: being understood, accepted and connected with a sense of belonging

2. Catharsis: expressing feelings and getting things out in the open

1. Interpersonal input: learning more about our impression and impact on others

The clients were unaware of the different categories, and simply rated each of the 60 individual items in relation to how helpful it had been to them.

What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a very helpful element of the therapy process, even though this is exactly what most of the clients are initially looking for. What is far more important is the client developing a deeper knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.

The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):

10. Feeling more trustful of groups and of other people.

9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.

8. Learning how I come across to others.

7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.

Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months, and were either about to finish their treatment or had recently done so. Obviously these items were in relation to group therapy, so the most important factors for change across treatment in individual therapy may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.

For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.

If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, a longer-term psychological therapy may be just what you need!

20 Signs of Unresolved Trauma

Many people enter the therapy process with minimal awareness of their trauma history. When the trauma survivors are dissociative, they have the ability to block out an awareness of their trauma. They may know that their family had problems, or that their family was dysfunctional, etc, but they may believe they were never abused.

child abuse (Photo credit: Southworth Sailor)

However, blocking out conscious awareness of trauma does not mean that the survivors have no effects of that trauma. Using denial and dissociative skills does not mean that the abuse did not happen. Denial means that the person simply is refusing to acknowledge or accept the fact that they were traumatized. They are pretending they were not hurt, when they were actually hurt very badly.

Even if the memories of abuse are hidden from the survivor’s awareness, blocked trauma / unresolved trauma creates very noticeable and obvious symptoms that can be easily seen in their every day lives.

People will enter therapy aware of some of the following symptoms, but they may not realize these complications are suggestive of unresolved trauma issues:

These same symptoms can be applied for survivors already working in therapy. Attending regular therapy does not mean the clients have resolved their trauma issues or that they are even working in that general direction. Many therapy clients will continue to deny, dissociate, and refuse to look at their trauma even if they are aware of their daily struggles.

If you are experiencing a number of the symptoms listed above, ask yourself if you are truly ready to address your trauma issues, or if you find it more comfortable to continue living with these struggles.

Is it harder to face how you were abused and who abused you? Or is it harder to live a life full of depression, anxiety, thoughts of suicide, troubled relationships, extreme fears, physical pain, and addictions?

Running from your trauma history will not help you feel better. In the short-run, you might not have to face the issues, but the cost in the long-run of unresolved trauma weighs more heavily than you might suspect.

Like this:

You could just see his back. His face was hidden from view, but you still tried to read him. But you failed. You did not know what he felt, what his history was or where he was going. And in that moment, he didn’t either.

He sat waiting for the doctor. The door goes up, and a man in a white coat and thick glasses peer out: “Henry Wall” he calls. His handshake is firm before he points to the chair where Henry can sit. Henry sits down nervously, looking around in the room, feeling his heart beat hard in his chest. The doctor sits in front of the screen, his eyes searching intently for something.

“So, what can I do for you?” He barely looks over at Henry, but reach for a cup of coffee next to the computer.

“Well, I haven`t felt so good recently..”.

“Yes, I see that you have a history with several cases of the flu. It`s that time of year!”.

Henry looks down, its more of a mental flu, but how can he explain? The doctor writes something that must be “flu”.

“So, how long have you been sick”

“Well, it all started…”

“Give me days!” The doctor interrupts, the lack of patience obvious even if he tries to suppress it.

Henry looks at him, swallowing the lump in his throath.

“Well, I`m not exactly sure..”

The doctor looks irritated, waits for more information.

“Maybe.. A week?”. Suddenly this has become a contest. Like if he has the right answer, he will get one of those small presents children get when they have been brave at the dentist’s office.

The doctor nods. He continues to ask about the symptoms, and also listens to his heart and looks down his throat. He takes his blood pressure, and says it`s slightly elevated.

Henry answers as fast as he can on every question. When the doctors asks about low energy levels or fever, he starts to say “Well, I`m not sure exactly..”, and the doctor takes this as a confirmation on the reality of the symptoms, even if he didn`t say that he had them.

Before he went in, he had thought about if he could manage another day feeling like he does. He had been thinking about how easy it would be to not live anymore. He had wondered If anybody would care if he died, and even if somebody would find him in his house. Should he drive a car into the water? Could he make it look like an accident? In huge letters it professed that one in four suffers from depression, and it could help to see a doctor to get an appointment where you could talk with somebody. Maybe even medication. But now he just felt stupid.

He left the office with a sick-leave in his hand. He didn`t need it. He would never go to work again.

Reblogged from a psychologist who writes about Borderline Personality Disorder in a non-judgmental way. This is so important, and I thank the author for this nuanced view of the psychological challenges people with BDP face.

In 1980 the mental health industry invented a new diagnostic label, one of many, for the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The American Psychiatric Association (APA) presented DSM III to the world as a scientific revolution in psychiatric understanding. If people suffering emotional distress had accepted the APA’s statements about the new manual, they would have rejoiced that such a wealthy and powerful organisation had put its energies into making sense of psychological suffering. The vast majority of people receiving one of these new labels had experienced great trauma – sexual abuse, extreme life events and repeated abuses of power. Quite a progressive move by the APA then: understanding the effects of power on people. Psychiatrists could show care, understanding, and perhaps even provide a sense of solidarity to people who were marginalised. Unfortunately, in 1980 the APA willed Borderline Personality Disorder into being. The APA’s idea of empathy and understanding led to vast numbers of survivors of abuse being labelled as disordered individuals.

In many ways the diagnosis of BPD is an easy target for criticism and satire. The diagnosis of BPD is defined by a series of social and moral judgements, applied to people who have been traumatised and dressed up as a medical problem. If we had a friend who revealed to us after years of secrecy and shame that they had been repeatedly sexually abused as a child, our first response is unlikely to be “your personality must be really disordered – no wonder I’ve felt like rejecting you”. Instead we would show care, be amazed at their survival and probably feel anger at the perpetrators of abuse – basic common sense and decency. Sadly when it comes to psychiatric diagnosis good sense does not prevail. The survival of psychiatric diagnoses is in many ways an astonishing feat of magic; its supporters have woven a spell that repels good sense, compassion, logic and evidence.

There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within the individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).

Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.

If that doesn’t paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances – survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.

There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within the individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).

Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.

If that doesn’t paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances – survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.

Abuse and misuse of power are social and political issues. We seem to resistasking the questions that flow from this though. Such as why is sexual violence so prevalent in society? How do we prevent people doing horrendous things to each other in the first place? What economic policies decrease oppression and misuse of power in society? Going back to the 20th century, at one point the APA decided people who identified themselves as gay were suffering from an illness. Some of those who were labelled accepted and internalised the label. However due to lobbying and activism this idea was eventually abandoned. It is now time to speak up and say that people in emotional pain, who have suffered and attempted to survive, should no longer be labelled disordered. It is time to abandon the concept of borderline personality disorder and instead find and honour the person.

My fingers are freezing. Several people around me are sitting with their sleeves drawn down as far as possible, to keep the trinkets of warmth alive. The air-condition is spitting out its icy message: ‘I’ll make sure no drop of sweat manifests itself on your forehead’. I register it and think about the irony. Outside it’s actually quite warm, much warmer than it would be in Norway, but it seems people would rather feel cold than warm. I’m at the bus from Baltimore to New York and have for three hours read a book about self-harm.

Reflections are important for me

Several times I had to just stop and let my eyes rest on the view, since some emotions rose in me. It was some sense of happiness, growing in me after reading about different treatment-approachs ( to self-harm and problems with emotion regulation).

I also grew fond of the author, because of his integrity and obvious respect for his patients. He truly cares about them all, and this compassion awakened his ability to creative new thoughts that elegantly weaves into well-known models. He made them rich partly because they associated with other ideas. Together this was pure mind-candy for my psychology-hungry state of mind (who said not working was great?).
The spider-web of associations made my thoughts light up with memories of people I’ve met. So many of them have shown me love, and I feel gratitude curling itself like a cotton nest in my stomach.

The reason for putting the book aside and writing down this now, was because I read about a lovely metaphor that I just had to share with you. My heart immediately reacted with speeding up its heavy thuds, since what I read made perfect sense and resonated within me.
Maybe you will like it as much as me ?

Defensive walls in a bloody war

Imagine a wall defending a city. In the book this safety-precaution was compared to the defensive walls in the movie ‘the lord of the rings’. In one battle scene a city is on the brink of invasion by the orks. This means that every boy and man have go into battle regardless of their preferences or experiences. Even a little boy, shaking in his boots so that the too huge helmet clatter, must defend the city against the enemy. Everything looks hopeless until the elves suddenly appear. They help them so they survive and win, but only until they can fight for themselves.

Different constructions
The author of the book compares the war to defense. Their defense is iron-wrought pillars gathered from cuts that colored its surface. Sometimes their enemies (thoughts, emotions, memories or people they can’t trust) are lurking and they try to cement their construction with the few materials and resources they got or collected. Examples of the defensive actions can be to distract the beasts with carving their skin, believing this piece of art will awaken the hunger of the beasts. Like martyrs they settle for contributing what little they know and can do.

If the enemy has been inoculated against bloody fingerprints the fierce fighters can jump over the walls in full destruction-mode (By acting out and possibly hurting both friend and foe). As the enemies draw closer,the unexperienced heroes of war, become afraid and desperate. This in turn colors the type of defensive strategy they unmask. Often they go from mental to continually concrete and physical types of defense (from denial and avoidance to self-harm or violence). Ignoring the orks will sadly mean feeding the orks with their souls. For an eternity.

Is it really strange that they use the only defense they can think off when it looks like the walls will not hold ? When one feel control slipping away, ‘irrational things’ like cutting themselves might be the only mechanism they had that brought relief.

Think about the samurai’s from Japan: By killing themselves, they didn’t have to face the shame of losing against their enemies. Further; What about all the lovely people who tries to hide their ‘dark’ emotions because they think people will shunt them if not? Isn’t it understandable that instead of letting other respond to their emotion, they rather run away from it than to face it, especially when considering the addition burden of trauma many have in their pasts?

A child who misbehaves and gets punished for it might harvest their own baskets of anger. Is it strange they can be terrified of their parents ‘discovering’ they’ve been cutting their skin, when they sometimes believe they always do wrong and deserve what they get? What can we therapists do ?

When a patients shows you the honor of telling about their shameful thoughts and actions, try to not be the ‘enemy’ who wants to breach the walls. Let them see that you come in peace, and wait until they feel safe enough to look over the wall for a bit, thereby letting us discover their battle scars from earlier war-zones. Remember that they naturally can be extremely sensitive and guarded after such experiences .

It’s sometimes easier to attack first than risking getting an arrow in your heart, and our job is to respect that and fight along with them, just like the elves.

Follow Blog via Email

Older posts:

I am a psychologist working as a trauma therapist in Norway.
I am blogging about my life and psychology-related topics. I am also working on a book about my life and work, that will be published this year.
Thank you all for visiting my blog.